Translating Family-Focused Prevention Science into Public Health Impact

Underage drinking is a pervasive problem in the United States, with serious consequences for youth, families, communities, and society as a whole. Family-focused preventive interventions for children and adolescents have shown potential for reducing underage drinking and other problem behaviors. Research findings indicate that clear advances have been made, in terms of both the number of evidence-based interventions available, and in the quality of the methods used to evaluate them. To fully reap the benefits of such preventive interventions and achieve public health impact, the findings of family-focused preventive intervention science must be translated into real-world, community practices. This type of translation can be enhanced through four sets of translational impact factors—effectiveness of interventions, extensiveness of their population coverage, efficiency of interventions, and engagement of eligible populations, with sustained quality intervention implementation. Findings from studies conducted by researchers at the Partnerships in Prevention Science Institute and other empirical work highlight the importance of these factors. A model for community–university partnerships has been developed that potentially can facilitate the dissemination and public health impact of universal interventions to prevent underage drinking and other problem behaviors. This model fits well within a comprehensive strategic framework for promoting effective prevention.

U nderage drinking is a serious public health concern that places an enormous burden on affected youth, families, communities, and society as a whole. The pervasiveness of the problem is illustrated by findings from the Monitoring the Future Survey (Johnston et al. 2010), showing that even among 8th graders, about 15 percent had consumed alcohol in the month preceding the survey; this increased to almost 45 percent among 12th graders (see table  1). Furthermore, a significant proportion of the youth surveyed reported that they had been drunk in the month preceding the survey.
In addition to being illegal, underage drinking is especially worrisome because it can have a longterm or, in some cases, lifelong impact on an adolescent's physical and intellectual development. For example, alcohol consumption might adversely affect the stilldeveloping brain, causing poten tially lasting changes in brain structure and function that are likely to negatively influence the individual into adulthood (Tapert and Schweinsburg 2006;Tapert et al. 2008). Also, adolescents who indulge in heavy drinking are likely to engage in risky behaviors, such as drinking and driving; traffic accidents pose the single greatest mortality risk associated with underage drinking (Grunbaum et al. 2002;Hingson and Kenkel 2004;Hingson et al. 2005). Likewise, alcoholrelated risky sexual behavior (e.g., unprotected sexual activity) can lead to consequences such as sexually transmitted diseases and pregnancy (Grunbaum et al. 2002;Hingson et al. 2004; National Institute on Alcohol Abuse and Alcoholism [NIAAA] 1993). Moreover, adoles cents who drink alcohol are at increased risk for behav ioral problems, such as delinquency, violence, and poor academic performance (Hingson et al. 2002; Substance Abuse and Mental Health Services Administration [SAMHSA] 2008) and mental health problems, such as depression and suicidality (NIAAA 1997;Swahn et al. 2008;Windle and Windle 2001). Finally, underage drinking increases the risk for using other drugs during late adoles cence and into adulthood (Ellickson et al. 2003) as well as for developing alcohol use disorders (AUDs)-that is, alcohol abuse and dependence-during adulthood (Dawson et al. 2008;Grant and Dawson 1997). In addition, these consequences of underage drinking result in sub stantial economic costs, which have been estimated to be approximately $62 billion per year (Foster et al. 2003;Levy et al. 1999).
Studies on the etiology of adolescent problem behaviors such as underage drinking indicate that such problems are influenced to a large extent by family factors. These influ ences can both increase the risk of problem behaviors and protect against the development of such behaviors. Thus, a family history of AUDs or certain parenting behaviors (e.g., inconsistent or harsh discipline) can increase a child's risk of early alcohol use and later development of AUDs (Hussong et al. 2008;Latendresse et al. 2008). At the same time, family factors can reduce the likelihood that an adolescent will experience alcoholrelated problems. Most importantly, an effective, positive parent-child relationshipcharacterized by child monitoring, parental involvement in the child's daytoday activities, and parent-child bonding or affective quality-provides a scaffold that helps children and adolescents develop the adaptive skills (e.g., self regulation, emotion, and behavior) needed to protect themselves from underage alcohol and other drug (AOD) use (Elias et al. 1997;Masten and Coatsworth 1998;Mrazek and Haggerty 1994). Because family influences are so pivotal in shaping adolescent problem behaviors, much research has centered on familyfocused prevention approaches to reduce prob lem behaviors. For example, many welldesigned studies have demonstrated that familyfocused interventions (e.g., programs that focus on parenting practices, such as parentchild communication, parent-child bonding, and effective family management) can reduce problem behaviors in chil dren and adolescents. Familyfocused interventions can be successful both for general populations and for families with adolescents who exhibit more serious delinquent behavior (for a review, see Spoth et al. 2002c).
This article reviews the current state of familyfocused prevention research and explores in more detail how these interventions can be translated from research projects to realworld settings. The authors summarize key findings from studies of various interventions and, as requested, focus on a program of partnershipbased research at the Partnerships in Prevention Science Institute (PPSI), for illustrative purposes. They then discuss how the translation of existing and new interventions can be enhanced and how the translational impact of these interventions can be supported. This discussion primarily centers on a PPSI developed model for community-university partnerships that focuses on the prevention of underage drinking and other problem behaviors, along with the national network that will support these partnerships.

Moving Toward a Paradigm of Public Health Impact
To date, most of the familyfocused interventions tested and proven to be effective only have been implemented with relatively small groups of adolescents and their families, either as part of a research project or as part of a small scale dissemination effort. To fully reap the benefits of such preventive interventions and achieve a public health impact, it is necessary to translate the practices and find ings of familyfocused intervention science into realworld public health practices that can benefit large numbers of children, adolescents, and families. Therefore, it is essential that researchers, health care providers, relevant health services agencies, and policymakers adopt scienceto practice translational models oriented toward public health impact. Such models should ensure that programs and practices that are implemented on a large scale already have been proven to be effective (i.e., meet standards of evidence, such as those developed by the Society for Prevention Research [Flay et al. 2005]) and are imple mented with sufficient quality on a sustained basis in community settings. These robust standards of evidence currently are met only by a limited number of programs and practices. In other words, although numerous family focused interventions already are implemented in the United States, by far the majority of these interventions have not yet been rigorously evaluated. It is important to note that few interventions have demonstrated positive, longterm effects in rigorous studies, and fewer still are being implemented with sustained high quality (Spoth 2008).
Because of the limited largescale dissemination and implementation of existing, evidencebased familyfocused preventive interventions, it is critically important to pay close attention to specific factors influencing the translation of familyfocused intervention research into largescale, realworld applications. This requires that research, from the earliest developmental stages of an intervention onward, needs to take into consideration factors that ulti mately could influence eventual largescale implementa tion, such as consumer preferences. Even the most effective intervention likely cannot be implemented effectively on a large scale if the consumers (i.e., adolescents and their fam ilies) cannot be engaged sufficiently because, for example, the program requires too much of a time commitment.

Current Status of FamilyFocused Preventive Intervention Research
Although, as suggested above, it is clear that family focused intervention can be of great benefit, the full potential of these interventions has not yet been realized. Nevertheless, over the past quarter century, researchers have made significant advances in familyfocused and other types of prevention research-that is, in the devel opment and rigorous evaluation of effective interventions.
Advances in the field of familyfocused prevention research have been achieved across universal, selective, and indicated types of interventions (for reviews, see Alexander et al. 2000;Spoth 2008). (For a definition of the different types of interventions, see the text box.) Several advances are particularly noteworthy. First, universal interventions have shown longterm effects across a range of AOD misuse and related outcomes (e.g., healthrisking sexual behavior or offending behaviors) for as long as 10 years past the baseline assessment of the outcome study (e.g., Spoth et al. 2009c). Longterm effects are mediated by delayed ini tiation of substance use, including underage drinking.
Second, selective interventions have been developed that easily can be integrated into Nationwide service programs, such as Head Start. Of importance, although these interventions necessarily initially are tested among relatively small populations, some of them have been devel oped from the outset with plans for subsequent, scaledup implementation in large and diverse populations so that they can achieve a measurable public health impact.
Third, there is evidence of increased attention to cultur al sensitivity of new programs, to ensure their applicability in different population subgroups. Finally, evaluation of familyfocused preventive interventions increasingly has followed rigorous scientific standards, starting with inter vention designs based on theory and continuing with outcome assessment using randomized, longterm studies with followup periods of at least several years.
Taken together, these advances have provided important information to researchers and clinicians alike, both on risk and protective factors for relevant problem behaviors among children and adolescents and on effective family focused interventions aimed at preventing underage drink ing and promoting positive youth development. However, although the potential for widespread dissemination of evidencebased familyfocused interventions clearly exists, many challenging tasks remain.

Review of FamilyFocused Preventive Interventions
In a recent comprehensive literature review, col leagues (2008a, 2009a) summarized the current state of the evidence regarding the effectiveness of all types of preventive interventions for underage drinking. The researchers identi fied more than 400 interventions that targeted different age groups (i.e., less than 10 years, 10 to 15 years, and 16 to more than 20 years) and were directed toward one or more of the different domains of the participants' lives (e.g., school, family, or workplace). Of those interventions, 127 had suffi cient information available to allow for an analysis of their effectiveness on the basis of six criteria (Spoth et al. 2008a). 1 According to the extent to which these criteria were met, the researchers categorized the interventions into three groups: • Interventions with the most promising evidence-these interventions met all six evaluation criteria, with the authors of the review making an overall judgment of how well the criteria were met; • Interventions with mixed or emerging evidence-these interventions did not meet all six criteria but provided some evidence of effectiveness (e.g., they demonstrated a positive effect in some studies and no effect in other studies, demonstrated positive effects on some but not all measures, showed effects only in some subgroups of the

Different Types of Preventiv Interventions e
Depending on the target audience, inte be classified into three categories: • Universal interventions are designed for all individ uals in a given population (e.g., all middleschool students and their families in a given school district).
Selective interventions are designed for specific pop ulation subgroups that as a whole are at higher risk of problem behaviors such as underage drinking (e.g., all students in a community who exhibit certain problem behaviors, such as antisocial behavior, and their families).
Indicated interventions are aimed at specific individuals who have risk factors or conditions that place them at particularly high risk of a problem behavior such as underage drinking and related problems (e.g., ado lescents who have been caught driving intoxicated).
rventions can • • sample, or demonstrated effects but had some substantial methodological limitations); and • Interventions with insufficient or no evidence of effectthese included all interventions that did not fall into any of the preceding categories.
Using this approach, a total of 12 interventions were classified as most promising and 29 interventions were classified as having mixed or emerging evidence (see table 2). The interventions with at least some evidence of effective ness covered the entire range of included age groups as well as targeted family, school, and community or work place contexts. The analysis also supported the important role that family factors play in shaping children's and adolescents' behavior, especially among those ages 15 and under. At least 9 of 18 interventions aimed at children younger than 10 years of age and at least 5 of 13 interven tions aimed at adolescents aged 10 to 15 years targeted the family domain. The following paragraphs briefly summarize some of the familyfocused interventions and multicomponent interventions with a family compo nent. For more detailed information on other preventive TARGETED PREVENTION APPROACHES-WHAT WORKS interventions for underage drinking, see the review by Spoth and colleagues (2008a).

Interventions for Children Under Age 10 With Most
Promising Evidence. Few children under the age of 10 consume any alcohol. Therefore, interventions for this age group typically are designed to address other behavioral problems that often precede underage drinking (e.g., aggressiveness). By ameliorating these preceding problem behaviors, subsequent initiation of alcohol consumption can be prevented or least delayed. Two of the interven tions directed toward children under the age of 10 that showed most promising evidence of effects on alcohol related outcomes were specifically designed for parents or families. The remaining interventions were delivered as universal interventions to gradeschool students and included both parent or familyfocused and school com ponents. Each of the programs showed positive effects among the participating children. For example, the Linking the Interests of Families and Teachers intervention delivered in grade 1 led to reduced physical aggression in the chil dren; in addition, when delivered to grade 5 students, it influenced alcoholuse patterns in middle school. Likewise, the Raising Healthy Children intervention resulted in less disruptive and aggressive behavior and later reductions in growth of alcohol use (although alcohol initiation rates did not decline). The Seattle Social Development Project demonstrated effects on aggression (at least in white boys), alcohol initiation in grade 5, and heavy drinking at age 18. A familyfocused intervention for this age group, the Nurse Family Partnership Program, was designed specifically for lowincome pregnant women. This program not only reduced mothers' behavior problems attributable to AOD use but also resulted in fewer days of alcohol consumption among their offspring at age 15.
In summary, all of the programs for children younger than age 10 with the most promising evidence of effec tiveness exclusively or centrally address the role of family related factors in the development of problem behaviors (e.g., underage drinking and behaviors that precede it). preschool, multicomponent) • TriplePPositive Parenting (family) * * F Fo or r a a d de es sc cr ri ip pt ti io on n o of f t th he e v va ar ri io ou us s i in nt te er rv ve en nt ti io on ns s a an nd d t th he ei ir r e ev vi id de en nc ce e, , s se ee e S Sp po ot th h a an nd d c co ol ll le ea ag gu ue es s ( (2 20 00 08 8a a) ). .

Interventions for Children Under Age 10 With Mixed or Emerging Evidence.
Although most of the 13 inter ventions in this category included schoolbased strategies, some also included familyfocused components, either alone (e.g., I Can Problem Solve) or in combination with schoolbased and other components (e.g., Families and Schools Together, Perry Preschool Program, The Incredible Years, Triple PPositive Parenting). For example, the Families and Schools Together program involved 100 American Indian children of kindergarten and early grade school age; outcome research showed effects on aggression. Similarly, the I Can Problem Solve program involving 217 African American preschoolage children led to a reduction in impulsive behavior, which is considered a risk factor for early initiation of alcohol use. In the Perry Preschool Program, which was studied with 123 primarily African American preschoolers, the investigators noted reduced antisocial behavior at the followup assessments, although there were no differences in later adult alcohol use. The Incredible Years program was evaluated in three different samples of preschoolaged children. In each of these analyses, the researchers noted improvements on some measures but not on others, or the effects only were observed in subsamples of the children studied (e.g., those at higher risk). Finally, the Triple PPositive Parenting intervention, which was evaluated with preschoolers in Germany and Australia, resulted in lower levels of externalizing behaviors (e.g., aggression and other problem behaviors).

Interventions for Adolescents Ages 10 to 15 With Most
Promising Evidence. Early adolescence, with its transitions to middle and then high school, as well as the physiological and emotional changes brought on by puberty, is when many youth start experimenting with AODs. Epidemiological research has shown that the earlier an adolescent begins drinking alcohol, the greater is her or his likelihood of developing an AUD or other alcoholrelated problems; therefore, interventions aimed at this age group might play a pivotal role in preventing alcohol initiation and its associated harmful consequences.
Several interventions have been developed that are directed toward this age group; many use a familyfocused program, or a multicomponent approach that includes family components. One familyfocused program in the "most promising evidence" category is the Strengthening Families Program: For Parents and Youth 10-14 (SFP 10-14). In one study, this intervention led to significantly lower rates of drinking and drunkenness at 4 years after base line; moreover, alcohol initiation was delayed and lifetime alcohol use and drunkenness were significantly reduced at 6 years after baseline. More recent results from this study demonstrated that positive effects on reduction of alcohol related problems extended into early adulthood (Spoth et al. 2009c). In a second study, the SFP 10-14 was imple mented in combination with a schoolbased life skills training program. Findings from this study indicated that through 5.5 years past baseline, growth in alcohol and drunkenness initiation was significantly slower among adolescents receiving the intervention than among control adolescents, although not among a higherrisk subsample (Spoth et al. 2008c). These observations confirm that family focused interventions can positively affect alcoholrelated outcomes of adolescents at this particularly vulnerable age.
Two multicomponent interventions-Midwestern Prevention Project/Project Star and Project Northlandincluded familyfocused components in addition to schoolbased and communitybased components. These interventions also generated a variety of positive effects. For example, compared with adolescents from a control group, significantly fewer participants of Project Star reported pastweek and pastmonth alcohol use. Among the partic ipants of Project Northland, those who had received the intervention in grades 6 through 8 reported significantly lower pastweek and pastmonth alcohol use, compared with controls, at 2.5 years after baseline, and those who received the intervention in grades 11 and 12 reported significantly less binge drinking at 6.5 years after baseline.

Interventions for Adolescents Ages 10 to 15 With Mixed or Emerging Evidence.
Studies of two familyfocused interventions for adolescents revealed mixed or emerging evidence of effects on alcoholrelated outcomes. For example, the Family Matters program that was evaluated with ado lescents from random households across the United States showed significant effects on lifetime alcohol use when the participants were assessed repeatedly; however, the size of the effects declined over time. Another interven tion, Families That Care: Guiding Good Choices, reduced growth in alcohol use, pastmonth alcohol use, and past month frequency of alcohol use at 4 years after baseline but did not significantly reduce pastyear alcohol use. The New Beginnings program was developed for families that included 9 to 12yearold children and their newly divorced custodial parents (mostly mothers); the interven tion was directed either at both the mother and the children or only at the mother. Results from the outcome evalua tion showed significant differences in pastyear alcohol use frequency only among those families where only the mother had been targeted by the intervention; in that group, effects only were observed among participants with higher baseline alcohol use levels. Finally, an intervention called SODAS City, in which the content was delivered via a CDROM alone or in combination with a parent intervention, showed significantly lower pastmonth alcohol use at 3 years after baseline.

Conclusions.
Taken together, review findings suggest that familyfocused interventions can make a significant differ ence in children's and adolescents' lives, reducing their risk of underage drinking and its negative consequences. To date, many interventions have been administered to children 10 years of age or younger, when more of their time is spent with their families. They mainly focus on building healthy parent-child relationships, decreasing aggressive behavior, and strengthening the children's social and cog and transferred into community practices that can have a nitive competence for the transition into school. However, positive impact on the future of adolescents and, conse because of the young age of the children involved, the quently, a substantial public health impact. studies primarily assess risk factors that often are precur sors of later alcohol use, such as aggressive behavior, rather than direct alcoholrelated measures. Only studies with even longer followup periods can address whether these early interventions indeed reduce underage drinking, and particularly harmful drinking patterns, such as binge drinking. On the other hand, limited research has been conducted on interventions implemented during the "tween" years (later elementaryschool years). Additional attention needs to be paid to the effects of familyfocused interventions delivered during the middleschool years, when many young adolescents have their first experiences with alcohol. Finally, several familyfocused interventions or multicomponent interventions with a familyfocused component have shown evidence for reducing underage drinking and harmful drinking patterns even after extended followup, into young adulthood.
To transfer benefits demonstrated by the reviewed studies to the adolescent population at large, researchers now need to focus on translating these interventions into larger scale implementation. The next section summarizes some of the recent advances in the translation of research on familyfocused preventive interventions into effective, widespread application that achieves public health impact.

Translating FamilyFocused Intervention Research into Public Health Impact
For effective translation of evidencebased interventions into widespread practice that can have a real public health impact, four general steps can be helpful to consider (see figure 1). A first step is to enhance the translation of pre ventive interventions by considering not only the scientifi cally sound development and testing of the program but also considering, very early on, how organizational and systems factors specific to various practice settings ulti mately will influence adoption, implementation, and sustainability of the program. A second step involves careful attention to specific sets of factors that influence the translation of interventions into widespread practice. These factors, also known as the "four Es of intervention impact," will be described in more detail in the following sections. As a third step, mechanisms can be developed to facilitate the translation from research into practice-for example, practitioner-scientist partnerships and networks (these also will be discussed later in this article). Finally, a fourth step provides direction to the translational process by establishing appropriate guidelines and standards for translationrelated research (e.g., standards on how inter vention outcomes should be measured and how public health impactoriented research should be reported and disseminated). Following all of these steps helps to ensure that effective familyfocused interventions are developed

The Four Es of Intervention Impact: Illustrations From PartnershipBased Research
The following four factors are particularly important when considering the translation of preventive interven tions, regardless of whether these interventions focus on the family or another contextual domain (Spoth 2008): • The effectiveness of interventions; • The extensiveness of their coverage of all populations potentially benefiting; • The efficiency of interventions; and • The engagement of populations and quality of interven tion implementation with them.
The following sections address each of these factors in turn. Each section includes examples from extant research, many of which are illustrative examples from the authors' program of research at the PPSI, as suggested for this article.

The Effectiveness of the Intervention
The effectiveness of an intervention refers to the extent to which an intervention achieves a desired outcome, such as reduction in alcohol consumption, reduction in harmful drinking patterns, or reductions in related outcomes (e.g., alcoholrelated traffic accidents or injuries) and is the most obvious requirement for serving the translation function and public health impact of preventive interventions.
Establishing effectiveness requires welldesigned, methodologically sound studies that demonstrate practically significant outcomes, showing that the intervention can be considered to be "evidence based" (e.g., as per the outcome evaluation criteria described earlier). The results optimally can be replicated in independent studies. Moreover, researchers need to monitor and establish the longterm effects of the intervention, particularly when the desired effect (e.g., reduction of underage drinking) will be achieved only at some point in the future (e.g., when the intervention occurs during primary school or early middle school) or is supposed to persist for extended periods of time (e.g., throughout an adolescent's school years). Researchers also should determine the core components or key mechanisms of the intervention that primarily are responsible for the intervention's effects. Finally, in the case of targeting general populations, the universality of the particular intervention's effects-that is, that the effects are observed across subgroups of participants that vary in risk levels-needs to be demonstrated. Several stud ies of familyfocused preventive interventions, including those conducted at the PPSI, illustrate how the effective ness of interventions can be evaluated and supported.

Analysis of LongTerm Effects.
Although relatively few studies of familyfocused preventive interventions have demonstrated longterm effects (i.e., at least 2 or 3 years past intervention implementation), the review summa rized earlier uncovered some key studies in that regard. For example, a longterm followup study of the SODAS City intervention, which is a universal CDROM-based curriculum that includes a parent component, showed positive effects 3 years past baseline (Schinke et al. 2004). The Nurse Family Partnership program (Olds 1998) also has demonstrated replicated, longterm effects and quality implementation. Multiple randomized controlled trials have shown positive longitudinal motherandchild outcomes, including reductions in child abuse or neglect and fewer arrests for both mothers and their 15yearold children (also see www.nursefamilypartnership.org).
Another set of illustrative studies of longterm intervention effects comes from several randomized controlled clinical trials conducted by researchers at the PPSI (e.g., see Spoth 2007 for an overview). The purpose of these trials was to investigate the longterm effects of the interventions on alcohol and gateway substance-related outcomes in ado lescents. The aim of one study (Spoth et al. 2004a) was to analyze the effects of two brief familyfocused interventionsthe sevensession Iowa Strengthening Families Program (ISFP) and the fivesession Preparing for the Drug Free Years (PDFY) program, delivered when the participants were in the sixth grade-on AOD use initiation 6 years after the baseline assessment. Throughout the followup period, the investigators examined a variety of alcohol, tobacco, and other substance use measures. Both family focused interventions were able to slow the growth of initiation of AOD use over a 6year period, with greater or more widespread effects seen for the ISFP. In a subsequent analysis (Spoth et al. 2009c), the investigators examined whether the delayed AOD use initiation reduced prob lematic AOD use during young adulthood, about 10 years after baseline. To this end, the researchers evaluated selfreports of several youngadult AOD use frequency measures. The analysis indicated that the effects of the interventions on adolescent AOD initiation indirectly led to a significant reduction in the frequency of a number of these measures.

Effects Across Subgroups Targeted by Particular Universal Interventions.
Another important aspect of the effectiveness of general population interventions and their potential for translation to populationlevel impact is the universality of effects-that is, whether a particular inter vention can be applied to, and generate positive effects for, all members of the specific population targeted or whether it is more or less effective in certain population subgroups. This includes, for example, genderspecific subgroups (Mason et al. 2009) and subgroups defined on the basis of risk profiles, including having a family history or other risk factors that predispose an adolescent toward AOD use. The relevance of this translation factor can be illustrated by an analysis of data from the previously men tioned study of sixth graders receiving either the ISFP or PDFY program interventions (Spoth et al. 2006b). For this analysis, the investigators divided the participating families into a lowerrisk and a higherrisk group, based on 10 riskrelevant measures (e.g., the parents' marital status, household income and financial strain, or presence of other psychiatric problems in the mother, father, or child).

TARGETED PREVENTION APPROACHES-WHAT WORKS
The analysis indicated that both interventions had com parable effects on alcohol initiation and illicit drug initia tion; moreover, these effects were independent of the risk status of the family (i.e., the interventions were equally effective for adolescents from lowerrisk and higherrisk families). These findings support the universality of the two familyfocused interventions studied. Other analyses, however, have indicated that some dif ferences in effect depend on certain riskrelevant factors (e.g., parent education or household income [see Spoth and Redmond 2002]). Specifically, some interventions in some studies seemed to be more effective for youth from higherrisk families than in youth from lowerrisk families. Spoth and Redmond (2002) proposed two mechanisms that may account for the greater benefit to higherrisk families: First, if higher and lowerrisk families are grouped together for the intervention, higherrisk families might begin to model behaviors from the lowerrisk families (e.g., effective communication and problemsolving skills), thereby improving their outcomes. Alternatively, lowerrisk families might be more likely to already apply the skills targeted by the intervention so that their overall benefits from the intervention are smaller than those of higherrisk families that have not yet been using those skills.
In cases where an intervention is shown to be less effective for higherrisk participants, it is important to consider a redesign of the intervention to better tailor it to higher risk participants. Researchers previously had speculated that many intervention approaches, particularly brief, universal interventions, most likely would have greater benefits for lowerrisk adolescents than for higherrisk adolescents (Offord et al. 1998;Spoth et al. 2008c). Nonetheless, as noted above, several more recent studies have suggested that familyfocused interventions can have the same or even greater benefits for higherrisk youth than for lowerrisk youth (Spoth et al. 2006b(Spoth et al. , 2008c.

Analysis of Key Mechanisms of Effects.
It is important not only to evaluate whether interventions produce a positive effect but to understand how they produce these positive outcomes. An approach called corecomponent analysis allows researchers to better understand which components produce effects through the application of mediation analyses. Conducting core component analyses of multicomponent interventions allows program developers to learn which components are the most efficacious and indicates where program implementers might receive the largest return for their investment. This is especially helpful because multi component interventions often are difficult to implement and expensive to replicate beyond the original research project. In one study of a multicomponent intervention called Project Northland, researchers conducted a post hoc corecomponent analysis to determine which of the key components-a classroom curriculum, a peer leadership component, extracurricular activities, a parentfocused program, and a community activism component-were driving the positive overall intervention outcomes (Stigler et al. 2006). The results indicated that only three of the five intervention components had a significant impact on alcohol use, suggesting that the remaining components were not essential ingredients.
To date, only a limited number of studies has used mediation analyses to examine mechanisms of effects for universal familyfocused interventions; however, one such study comes from the PPSI (Spoth et al. 2009b). In this study, the ISFP intervention was found to exert its effects by establishing a "protective shield" that reduced adoles cents' exposure to illicit drug use. The researchers hypoth esized that a familyfocused universal intervention during sixth grade would reduce the number of illicit drug expo sures or opportunities an adolescent had to use illicit drugs, thus providing a type of protective shield effect. The reduced exposure to drug use, in turn, was predicted to lower subsequent lifetime illicit drug use. Repeated waves of interviews of the study participants confirmed that, compared with adolescents in a control group, adolescents who par ticipated in the ISFP experienced less illicit drug exposure and were less likely to have initiated illicit drug use by the end of the study. These findings suggest a plausible mech anism through which the ISFP could reduce illicit drug use. 2 This finding was extended and replicated in a subsequent study. Overall, although a few studies have examined the mechanisms of effects, further study of the factors that mediate familyfocused intervention effects is needed.

The Extensiveness of Intervention Coverage of Diverse Population Targets
Achieving broad populationlevel impact depends greatly on the availability of evidencebased interventions for a wide range of targeted populations, including population subgroups defined by developmental stage. For example, for adolescents growing up in rural versus urban areas or having different ethnic backgrounds with varying cultural traditions, the family may play a different role in shaping their behavior. Accordingly, to have a broad public health impact, interventions need to be developed, tested, and disseminated to a wide variety of population subgroups and should address otherwise underserved populations. Basically, extensiveness of intervention coverage addresses whether interventions have been designed, tested, and proven effective for all relevant population seg ments, across developmental stages (i.e., across ages 1 to 20), with suitability to varying cultural contexts and settings.
Research has demonstrated that interventions designed for a more general American population (i.e., white, middle class) may not be well received by cultural subgroups that do not relate to program materials or messages inconsistent with the values and beliefs of their community (Kumpfer et al. 2002). According to GonzalezCastro and colleagues (2004), when such a "mismatch" occurs, intervention effi cacy, even with high levels of fidelity, becomes threatened.
There currently is a need for more interventions proven to be culturally competent. Greater cultural competence could enhance public health impact by increasing the like lihood that community members will be more highly engaged in intervention activities.
In an effort to increase the extensiveness of coverage of a preventive intervention, researchers at the PPSI (Spoth et al. 2003) conducted a pilot study that tested an adapted version of the previously mentioned SFP 10-14 to make the program more appropriate, culturally sensitive, and welcoming to AfricanAmerican families. This adaptation primarily focused on the presentation of the intervention (e.g., inclusion of AfricanAmerican families in program materials and use of AfricanAmerican facilitators) rather than on intervention content. In a study sample of 110 families, the intervention positively affected certain behaviors and skills in the adolescents who were targeted by the program, such as goal setting, stress management, and effective communication with parents, but not parenting skills. The participants' positive reaction to and acceptance of the program showed that interventions used primarily in the majority population could be successfully adapted for use in minority populations. Most notably, this pilot research contributed to a subsequent program of research that developed the Strong African American Families program.
On the basis of developmental research and cognitive models of adolescent health risk behaviors in African American families, the Strong African American Families program focuses on strengthening regulated, communica tive parenting processes (Brody et al. 2006). This means that the program instructs parents about the following: how to be involved in their children's lives and closely monitor their activities while providing high levels of emotional and practical support; how to clearly articulate their expectations regarding adolescents' alcohol use and sexual behavior; and how to provide racial socialization. 3 The investigators found that this program, when tested in rural AfricanAmerican families, could enhance these culturally relevant parent-child interactions and lower ini tiation rates of highrisk behaviors (Brody et al. 2006).

Efficiency of the Intervention
The term "efficiency" refers to the relationship between the costs involved in administering the intervention and the economic and other benefits resulting from the intervention. For example, given that two interventions generate the same beneficial effects, a brief, lowercost intervention, such as a selfadministered program, will have greater efficiency than a more extensive, highercost intervention, such as repeated counseling sessions with trained facilitators. In addition, interventions that generate additional effects not initially intended (i.e., crossover, nontargeted effects) are more efficient than interventions that produce only the intended effects.
Assessing economic benefits of interventions also pro vides some indication of possible efficiencies, including analyses of costs, costeffectiveness, and benefittocost ratios. To date, relatively few interventions have been evaluated with rigorous economic analyses of these types. The findings from such evaluations suggest that economic benefits vary considerably, ranging from very positive to negative. Among youthfocused prevention programs, analyses have demonstrated that several familyfocused interventions-or multicomponent interventions including familyfocused elements-designed to prevent adolescent AOD use (e.g., Project Northland, Project Star, Family Matters) can be cost effective and beneficial (Aos et al. 2004). In general, costeffectiveness data can help admin istrators conduct comparative analyses of interventions to better clarify which ones could likely produce a given effect at the lowest cost.
PPSI performed cost effectiveness and benefittocost analyses using data from the longterm study of the ISFP and PDFY programs mentioned previously (see Guyll et al. in press;Spoth et al. 2002a). Cost effectiveness was determined by estimating the costs of treatment to prevent one adolescent from subsequently developing an AUD. This cost was approximately $12,500 per case prevented for the ISFP and approximately $20,500 per case prevented for the PDFY program. Other analyses have indicated that preventing one case of AUD results in a lifetime benefit of approximately $120,000. Dividing this amount by the cost per case prevented yields the benefittocost ratio. Using this approach, the investigators found that for the ISFP, each dollar invested yielded a benefit of $9.60, whereas for the PDFY program, each dollar invested resulted in a benefit of $5.85. These findings demonstrate that familyfocused interventions that require relatively small administration costs can result in substantial cost savings to society by preventing or delaying the onset of AUDs.
Crossover effects also can increase an intervention's effi ciency. Familyfocused preventive interventions often are designed to target a number of proximal outcomes that previously have been shown to predict the desired longterm outcomes of interest, commonly described as risk and protective factors. These proximal outcomes can include protective factors (e.g., effective parenting, parent-child communication, and general relationship quality) as well as youth skills, such as the ability to refuse offered sub stances. The focus of the intervention might be to reduce gateway substance use, but because it targets risk and protective factors common to a range of problem behaviors or positive developmental outcomes, the intervention also might produce additional benefits beyond the one(s) primarily intended. In addition, because many problem behaviors frequently cooccur, reducing one problem behavior, such as substance use, is likely to "cross over" to reduce other problem behaviors as well. At a minimum, types of substance use not specifically targeted can be reduced (Spoth 2008;Spoth et al. 2006a). For example, one study of the effectiveness of the ISFP focused not on the program's effects on adolescent AOD use but on ado lescent aggressive, hostile, and destructive behavior . The investigators determined that the intervention reduced aggressiveness and hostility in the adolescents' behavior towards their parents (particularly their mothers) as well as outside of the home setting. Likewise, the ISFP has been shown to have positive effects on adolescents' engagement in school in grade 8, their academic success in grade 12, and internalizing symptoms (Spoth et al. 2008b;Trudeau et al. 2007). These nontar geted effects resulted from the program's positive effects on the proximally targeted outcomes, such as enhanced parenting skills and reduced risk of underage AOD use.

Engagement of Target Populations and Quality of Intervention Implementation
The best intervention cannot produce positive effects, particularly at the public health level, if it is not accepted by or engaging to the target populations. In addition to initially engaging target populations (e.g., recruiting families), it must be implemented sufficiently well to maintain engagement or retention and to produce expected outcomes. Of note, poor implementation quality, including low adher ence to intervention protocols, can substantially reduce intervention impact (Derzon et al. 2005).
Examples of engagement include recruitment of eligible families into the intervention, active participation by families during intervention sessions or activities, and attendance or completion of the entire curriculum. Research has indi cated that motivation to participate in an intervention among families in eligible general populations can be sig nificantly influenced by parent and youth characteristics and current behaviors as well as by family preferences and beliefs (Heinrichs et al. 2005;Pettersson et al. 2009;.  found that sociodemographic factors (e.g., ethnicity, edu cational attainment, or age of parents and children) have relatively little influence on recruitment and retention in universal interventions. Some studies, however, have indi cated that ethnicity and family status (singleparent versus dualparent families) can influence participation levels (e.g., Bauman et al. 2001;Rohrbach et al. 1994;Williams et al. 1995). Moreover, parent gender seems to play a role in intervention engagement because mothers seem to be more inclined to participate in a program . Parents' beliefs regarding child problem behavior (i.e., whether parents consider the child susceptible to teen problem behaviors and consider those problems to be severe) or the child's actual level of problem behavior also influence engagement (Heinrichs et al. 2005). Many families consider common adolescent problem behaviors (e.g., regular smoking and drinking or sexual activity) quite serious, although they often think that their own children are at low risk for these behaviors. Not unexpectedly, families that consider these problems to be serious frequently think that programs addressing these problems can be beneficial and therefore are inclined to enroll in such programs . In a study of the Family Matters curriculum, parents who believed that their adolescents would smoke in the future were more likely to participate in intervention activities whereas those who believed that their adolescents currently smoked were less likely to par ticipate (Bauman et al. 2001).
It is important to note that most of the information currently available on family engagement in preventive interventions comes from research staff-based recruitment efforts. However, these findings may not generalize to communitybased recruitment by community volunteers; the latter would be critically important for largescale implementation of evidencebased interventions (Glasgow et al. 1999(Glasgow et al. , 2003. One possible approach to promoting sustained recruitment and retention of participants for familycentered interven tions is through community-university partnerships, in which community agencies or volunteers primarily are responsible for recruitment of families but receive technical assistance from a universitybased team. One study from the lead authors' program of research found that this approach can result in relatively high recruitment rates compared with other communitybased recruitment rates reported in the literature (Spoth et al. 2007a). Specific features of an intervention (e.g., meeting times and locations, program duration, or facilitator background) also can affect family engagement decisions-for example, scheduling problems can serve as an important barrier to family par ticipation (Heinrichs et al. 2005). Researchers or organi zations seeking to implement an intervention need to pay attention to these factors to ensure acceptance by their target population.
Intervention implementer skills and other factors that influence the active, ongoing engagement of participants reflect on the overall quality of intervention implementa tion. As noted earlier, implementation is especially impor tant because it is associated with the magnitude of the effects of interventions; even in the case of interventions that have been shown to be highly efficacious, poor imple mentation quality can greatly diminish effects (Derzon et al. 2005;Durlak and DuPre 2008). A key indicator of implementation quality is the degree to which the inter vention is administered consistently, with strong adherence to the original intervention protocol. For this reason, intervention implementation quality often is considered to be one of the most important factors in translational research models (Society for Prevention Research, 2007, www.preventionscience.org). Quality monitoring is partic ularly important when interventions are implemented under realworld conditions by diverse communitybased organizations (Dzewaltowski et al 2004;Glasgow et al. 1999Glasgow et al. , 2003Spoth et al. 2002bSpoth et al. , 2007b.

Translational Impact Through Community-University Partnerships and Networks
As the preceding sections have demonstrated, family focused interventions have shown promise in preventing underage drinking and use of other substances-effects that can translate into significant health and economic benefits for the adolescents, their families and communities, and society as a whole. Moreover, a range of studies have demonstrated that research to date addresses a number of factors (e.g., effectiveness, efficacy, and engagement) required for a greater impact on public health. An important next step in more fully realizing the impact potential of these preventive interventions will be to ensure their widespread dissemination and sustained highquality implementation. A promising approach to achieving this goal is the establishment of partnerships between community organizations and researchers as well as largerscale networks of such partnerships.
Such partnerships can address specific public health objectives for familyfocused interventions, such as reduc ing adolescent AOD use or conduct problems. Moreover, community-research partnerships can help address the needs of underserved populations. For example, rural areas with their small, widely scattered, and diverse popu lations present a challenge for prevention research and implementation of existing interventions (Spoth 2007). Effective collaboration between researchers and rural practitioners can help address these challenges and facili tate the effective dissemination and implementation of familyfocused interventions. For these and other reasons, partnerships between researchers and communities are a central component of recommendations made by the National Research Council and Institute of Medicine (2009) for putting knowledge into practice in order to prevent youth problem behaviors.
The need for such partnerships was supported by a seminal analysis by Hallfors and colleagues (2002) who evaluated the effectiveness of community coalitions to prevent AOD abuse. These coalitions were organized at the grassroots level, bringing together diverse groups and agencies to provide community education and awareness, prevention, and treatment. Analyses reported by Hallfors and colleagues (2002) showed no positive effects of these coalitions on adolescent AOD abuse, although a subse quent analysis by Hingston and colleagues (2005) found reductions in alcoholrelated deaths in a subset of those communities. The investigators speculated that presence of many competing agendas and goals, lack of requirements to use tested and effective programs, and poor organization and implementation may have contributed to the very limited positive outcomes observed.
Although the concept of community-research partnerships seems logical, their actual implementation can be chal lenging, attributable in part to the different goals and methods typically used by researchers and community practitioners.
Researchers, for example, generally focus on basic inter vention science, taking a cautious, stepbystep approach to developing new interventions and aiming to conduct carefully controlled, randomized trials to demonstrate efficacy before moving on to dissemination of the program to larger populations. In contrast, community practitioners naturally are interested in practical solutions, regardless of whether they have been thoroughly tested, that can be applied immediately to the pressing problems in their community. Moreover, community practitioners often want to adapt existing interventions to their local needs and circumstances, whereas researchers often want to con duct replication studies with strict adherence to existing protocols in order to obtain a more solid research base (Spoth and Greenberg 2005).
Several approaches have been suggested to resolve these discrepancies in goals and methodology. For example, researchers and community practitioners should identify their overlapping goals early in the collaborative process (Price and Behrens 2003;Wandersman 2003). In addi tion, an ongoing, active interaction between scientists and practitioners is necessary throughout the process (Spoth and Molgaard 1999). When all stakeholders in communityresearch partnerships are aware of and respond to challenges, such partnerships can be of great value to all involved (Weissberg and Greenberg 1998).

The PROSPER Model As an Example for Community-University Partnerships and Partnership Networks
One partnershipbased delivery system that strives to ensure effective translation of scientifically proven inter ventions to prevent underage drinking and AOD use into widespread practice is called PROSPER (PROmoting School-community-university Partnerships to Enhance Resilience). This system links universitybased prevention researchers to two established programdelivery systemsthe Cooperative Extension System (CES) at landgrant universities 4 and the public school system (Spoth et al. 2004b). It evolved out of a program of partnershipbased research over the past 20 years (Spoth 2007) that had pro duced many of the studies described above and was fur ther developed by researchers at the PPSI at Iowa State University and the Prevention Research Center at Penn State University. It was specifically designed to test the effectiveness of a partnership that entailed small, strategic local teams as well as guidance from technical assistance partners, to facilitate sustained delivery of evidencebased programs (see figure 2). PROSPER's local teams are composed of three groups: • Countylevel CES agents, who often are trained in communityleadership development and therefore can provide education and support; • Elementary and secondaryschool representatives; and • Local community service providers and other stakeholders (e.g., parent and youth representatives, law enforcement, or faithbased institutions).
These local community teams are in direct contact with an intermediatelevel coordinating team consisting of CESbased prevention coordinators who provide direct technical assistance and administrative support, as well as act as liaisons with the universitybased State management team. The State management team includes prevention scientists, CES specialists, and other collaborators and provides oversight and guidance, particularly concerning program implementation and data collection. The interac tion of the community teams with the intermediatelevel prevention coordinator team and, through it, with the Statelevel management team, ensures that the programs are implemented in the communities with sustained high quality.
Another key feature of the PROSPER model is that the preventive interventions used are evidence based. Moreover, the PROSPER model initially offers a menu of several such interventions (e.g., the familyfocused SFP 10-14 and Guiding Good Choices interventions and the school based All Stars Program, LifeSkills Training, and Project Alert) from which each community team can select the familyfocused program and the schoolbased program that is most appealing or appropriate for their community. Eventually, the intervention menu is expanded. It is important to note that the researchers collect process data, allowing them to monitor how well the interventions are being implemented, as well as outcome data that address whether the interventions do indeed produce sustained The PROSPER partnership network team, comprising scientists and cooperative extension professionals, provides expertise and technical assistance to every PROSPER State Partnership to ensure that their implementation effort is successful.

PROSPER State Partnership
Community teams, led by county-based extension personnel (e.g., 4-H youth development or family and consumer sciences extension educators/agents) and co-led by a school district staff member, sustain the quality Implementation of family-focused and school-based evidence-based interventions.

Intermittent Contact
Extension-based prevention coordinators provide continuous, proactive technical assistance to community teams on all aspects of program adoption, implementation, and sustainability, and serve as liasons between the community team and the state management team.

Intermittent Contact
Vol. 34, No. 2, 2011 199 The University-based State management team is comprised of university researchers, faculty-level professionals, and extension administrators who provide evaluation support and administrative oversight for the effort within the Extension system. positive results for the adolescents, their families, and their communities.
To date, the PROSPER model has been implemented in four States-Alabama, Iowa, Pennsylvania, and South Dakota. Work now is underway to expand it to an addi tional seven States. Results from the PROSPER model evaluation project have been very positive across a wide range of youth, family, and community outcomes, as follows: • Numerous community teams successfully have been formed, progressed through the model's developmental phases, and delivered family and schoolbased interventions.
• Community teams have generated resources and sustained their programming efforts for up to 8 years.
• Community teams have consistently achieved relatively high recruitment and participation rates.
• Process data indicate that the interventions are imple mented with high quality, with greater than 90 percent adherence to the intervention protocols.
• The programs implemented by PROSPER community teams have resulted in enhanced family strengthening, parenting skills, and youth skills. In addition, adolescents participating in the programs have lower rates of drunk enness, cigarette use, marijuana use, methamphetamine use, and other drug use, compared with the control groups, up to 4.5 years past baseline (see Spoth et al. 2007c; also Spoth and Greenberg, in press, and the PROSPER Partnership Group Research Overview for published papers available at: www.prosper.ppsi.iastate.edu).
These and other findings demonstrate that the PROSPER model is an effective approach for the prevention of underage drinking and other drug use, with the potential for Nationwide implementation. In response to interest from other States, a team of individuals from Iowa State and Penn State Universities are in the process of building the capacity and infrastructure necessary to support a network of PROSPER State partnerships. This network team, made up of prevention scientists and CES specialists from the original PROSPER model evaluation project, will serve as trainers and technical assistance providers to new State management teams and prevention coordinators as they develop and sustain their PROSPER State partnership.
Another community partnership model-Communities That Care-now has randomized controlled trial-based evidence of efficacy, although it does not specifically involve a partnership with universities (Hawkins et al. 2007). The Communities That Care system guides communitybased coalitions through several activities, including the creation of a databased community profile, development of a long term action plan that includes selecting interventions that match communityidentified priorities, finding resources to support their implementation, and evaluating their outcomes. Regardless of which model of communitybased inter vention delivery is applied, it is critically important to create a comprehensive strategic framework for promoting and facilitating the spread of effective preventive interven tions against underage drinking and other drug use that have proven translational capability to all regions of the Nation for maximum public health impact. Particular attention must be paid to capacity building of human, technical/scientific, financial, and other organizational resources, which is crucial for sustained quality implemen tation of any type of intervention. Three main tasks are involved in creating such a framework (Spoth and Greenberg 2005, in press). First, for any type of innovation to be effectively transmitted, "diffusion networks" must be established that facilitate the flow of information about the innovation. For example, the Public Health Service has stated that in order to effectively deliver interventions on a large scale, an adequate infrastructure, including data and information systems, must be in place (U.S. Department of Health and Human Services 2000). Second, an appro priate research agenda needs to be developed concerning evaluation of the largerscale implementation of new interventions through communitybased intervention delivery systems. Relevant research questions include, for example, how complex communitybased partnerships can best be evaluated, addressing implementation issues across diverse realworld settings. Third, it will be necessary to identify relevant policies needed for community partnership based implementation of effective interventions on a large scale, such as policies regarding youth programming and community development, as well as economic policies to support such interventions. The Society for Prevention Research Task Force on Type 2 Translational Research is developing guidelines to foster a more strategic and systematic approach to such translational efforts (Society for Prevention Research 2007, available at: www.preventionscience.org).

Conclusions
Familyfocused interventions aimed primarily at preschool, primaryschool, and middleschool students and their fam ilies have shown promise in preventing underage drinking and other related behavior problems. Children and youth participating in these interventions have shown improvements in behaviors commonly preceding underage drinking (e.g., aggressiveness), age at onset of drinking, frequency and amount of drinking, and other relevant measures. However, the development and testing of additional inter ventions clearly is needed. It is especially important that researchers consider developing new interventions focusing on what is required to enhance their widespread translation, so that interventions that yield positive results can be implemented on a large scale in realworld settings and not just under the confined conditions of a research trial. To demonstrate the translational capability of new and existing interventions, researchers need to address the four Es-Effectiveness, Extensiveness, Efficiency, and Engagement-of public health impact.
To maximize the translational impact of preventive interventions, it also is critical to assure sustained high quality implementation of evidencebased, familyfocused interventions on a large scale. Partnerships between practi tioners in the community and universitybased scientists offer a promising avenue. Such partnerships can offer community providers and organizations the technical support they need to build the capacities required to implement an intervention and to maintain highquality implementation over a long period of time. At the same time, such partnerships can provide researchers with valuable feedback on what does or does not work in real world settings. One successful example of such a commu nityuniversity partnership is the PROSPER partnership model, which supports communities in implementing evidencebased familyfocused and schoolbased interventions. Before the potential of such partnerships can be fully real ized, however, a comprehensive strategic framework for expanding partnership networks, clarifying the necessary research agenda, and providing the necessary policy support needs to be developed. With the help of such a framework, effective interventions targeted at youth and their families can be implemented nationwide, reducing underage drink ing and its harmful consequences, in order to achieve true public health impact. ■